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19 Cards in this Set
- Front
- Back
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Provides encryption of a signature to prevent unauthorized use |
Digital signature |
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Records of terminated patients |
Closed records |
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Records of patients who have not been seen in over three years |
Inactive records |
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Provides the ability to order test, prescriptions and referrals using the computer |
CPOE |
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Records of patients who have been seen within the last three years |
Active records |
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A type of record or chart where the contents are kept in sections |
SOMR |
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A method of charting progress notes |
SOAP |
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Health information stored electronically by the patient |
PHR |
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A set criteria indicating how certified EHR systems are to be used |
Meaningful use |
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A type of record or chart that identifies the patients problems and organizes them |
POMR |
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Explain the purpose and ownership of the medical record |
The medical record is a legal document Also serves as a communication tool regarding services provided to the patient The facility that created the record owns the physical record The patient owns the information in the record per HIPPA and has the right to determine who has access to that information |
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Name 5 proper procedures for changing items in a paper record |
The person who made the error must correct it. Locate incorrect information Use black ink and draw a single line through it so it can still be read. Never erase entries Never use correction fluid or white out Place date of correction, your initials, and error in the record Enter the correct information |
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Explain the concept of NEED TO KNOW as it applies to the MA and the medical record |
No staff member can access files for information that they do not need to know. You cannot view a patients chart simply out of curiosity |
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List 5 benefits or advantages of the electronic health record |
Improved documentation Avoids medical errors Online patient access Cost saving Less space needed |
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What does a signed informed consent form in the chart mean |
It means the patient understands and consents to the procedure |
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When dealing with automated orders, what is the last step in the process (or anytime you are using a computer) |
Log out and make sure the screen is not visible to anyone |
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What is the correct procedure for making a correction in paper chart |
Use black ink and draw a single line, initial and date. Follow office protocol |
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What is the correct procedure for making a correction in an electronic record |
Locate the error, verify the change, and save the record |
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What is the correct procedure for sending an EHR alert |
Use proper Grammer and terms Do not include personal comments about patients And realize that the alert may become a part of the permanent record |
